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Carve In, Pay Out!

Ever wondered what the deal is with carving in versus carving out pharmacy benefits? Let's break it down in a way that's as entertaining as it is educational!


So, let's start with the basics. Carving in pharmacy benefits is when they're bundled up with medical benefits, usually managed by a big health plan or a third-party administrator (TPA) . On the other hand, carving out pharmacy benefits is like peeling off the pharmacy benefit from the medical one, allowing self-funded employers to take control outside of the health plan’s influence .


Now, here's the part that might make you cringe - carving in can cost employers an arm and a leg. They have little visibility into the performance of their pharmacy benefit, no access to sweet client-specific rates or rebates, and no auditing rights. It's like your pharmacy benefit is hiding in plain sight! In carved-in plans, the same insurance carrier handling medical benefits also owns the pharmacy contract with the Pharmacy Benefit Manager (PBM). So, there's not much focus on pharmacy alone. The result? Carved-in plans face challenges like limited choice, lack of control, and less-than-ideal reporting and analytics on prescription drug trends . Not fun, right?


But wait, there's a solution! By switching to a carved-out pharmacy benefit arrangement, employers can take charge of their prescription drug spending and lower overall benefits costs . It's like having the ultimate power to choose what's best for their company, their employees, and their members when it comes to pharmacy benefits, trend management programs, and contract terms . Plus, carving out allows employers to tap into dedicated pharmacy teams who know how to analyze data and provide the guidance needed to make informed decisions. Finally, they can get some insight into those plan-specific Rx details and understand what's going on with their benefits at every level. Exciting stuff!


So, whether you're into carving in or carving out, understanding the ins and outs of pharmacy benefits can make a world of difference. Ready to take control?


We got you!

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